Canada / Portugal Agreement
Applying for a Portuguese Old Age and/or Disability Benefit
Here is some important information you need to consider when completing your application.
Please ensure you sign the application. If you are signing with a mark, (for example: “X”) the
signature of a witness is required.
Your application must be supported by documentation. Please submit the documents requested.
Failure to complete the application and provide the requested documentation may result in delays in
processing your application.
Where original documents are specifically requested, originals must be submitted with your
application. You should keep a certified true copy of any originals you send us for your records.
Some countries require original documentation which will not be returned to you.
You may submit the original or a photocopy that is certified as true for any of the documents where
originals are not required. It is better to send certified copies of documents rather than originals. If
you choose to send original documents, send them by registered mail. We will return the original
documents to you. We can only accept a photocopy of an original document if it is legible and if it is a
certified true copy of the original. Our staff at any Service Canada centre will photocopy your
documents and certify them free of charge. If you cannot visit a Service Canada Centre, you can ask
one of the following people to certify your photocopy:
Accountant; Chief of First Nations Band; Employee of a Service Canada Centre acting in an official
capacity; Funeral Director; Justice of the Peace; Lawyer, Magistrate, Notary; Manager of Financial
Institution; Medical and Health Practitioners: Chiropractor, Dentist, Doctor, Pharmacist, Psychologist,
Nurse Practitioner, Registered Nurse; Member of Parliament or their staff; Member of Provincial
Legislature or their staff; Minister of Religion; Municipal Clerk; Official of a federal government
department or provincial government department, or one of its agencies; Official of an Embassy,
Consulate or High Commission; Officials of a country with which Canada has a reciprocal social
security agreement; Police Officer; Postmaster; Professional Engineer; Social Worker; Teacher.
People who certify photocopies must compare the original document to the photocopy, state their
official position or title, sign and print their name, give their telephone number and indicate the date
they certified the document.
They must also write the following statement on the photocopy: This photocopy is a true copy of
the original document which has not been altered in any way.
If a document has information on both sides, both sides must be copied and certified. You cannot
certify photocopies of your own documents, and you cannot ask a relative to do it for you.
Return your completed application, forms and supporting documents to:
International Operations
Service Canada
P.O. Box 2710 Station Main
Edmonton, AB T5J 2G4
CANADA
Disclaimer:
This application form has been developed by external
sources in cooperation with Employment and Social
Development Canada. The content and language
contained in the form respond to the legislative needs
of those external sources.
REQUERIMENTO DE PRESTACOES DE INVALIDEZ OU VELHICE DA SEGURANCA
SOCIAL PORTUGUESA
AO ABRIGO DO ACORDO ENTRE PORTUGAL E o CANADA
APPLICATION,FOR PORTUGUESE DISABILITY OR OLD AGE BENEFITS
UNDER THE PORTUGAL CANADA SOCIAL SECURITY AGREEMENT
-
D ~ M A N D EDE PRESTATIONS PORTUGAISES D'INVALIDIT~OU DE VIEILLESSE AUX TERMES DE
L'ACCORD DE S ~ C U R I TSOCIALE
~
ENTRE LE PORTUGAL ET LE CANADA
Assinalar a prestaqifo p t e n d i d a
Check the benefit for which y o u wish t o apply
Cochez l a prestation demand&
Pensgo d e invalidez
Disability pension
Pension &invalidit6
Pensifo de velhice
OM a g e pmsion
Pension d e vieillesse
PREENCHER EM LETRA DE MPRENSA I PLEASE PRINT / &CRIVEZEN LETTRES MOUL~~ES
INFORMAC~ES
SOBRE 0 SEGURADO I INFORMATION CONCERNING THE INSURED PERSON 1 R~NSEIGNE
MENTS CONCERNANTL'ASSURB
1.I. Nomes pr6prios / F i t names / Mnoms
Apelidos /Surnames / Noms & famille
1.
I
~ i d a d k&
s origan pormguesa devem indicar 0s nomes pr6prios e apelidos tal m o mhaam an documento oficial portuguEs (biiete del
identidade ou passaporte)
Citizens of Portuguese origin must indicate their first names and surnames as shown on an official Portuguese document (identity card or
passport)
Les citoyens d'origine portugaise doivent indiqua leurs prtnoms et noms de famille tels qu'indiqds sur un document officiel portugais
(carte d'i&ntid ou passeport)
I.
1.2.
N h e r o da Seguranqa Social Portuguesa
Portuguese Social Security Number
Numtro d'assurance sociale du Portugal
N h e r o da Seguranqa Social no Canad4
Canadian Social Security Number
Numtro d'assurance rociale du Canada
u
1111111111
N h m fiscal de contribuinte em Portugal (se possuir cartHo & contribuinte,juntar fotoc6pia)
Taxpayer number in Portugal (if you have taxpaycr card. please enclose a photocopy)
N h e r o fiscal au Portugal (sivous possedk une cartc f d e , veuillez inclurc une photocopie)
u
1.3.
Enderqo
Address
Adresse
1A.
1.5.
N h e r o . ma.apart.. caixa postal
Number. Street, Apt, P.O. Box
Numtro. rue app., case postale
Cidade ou localidade
City or Town
Ville ou village
Provhcia ou terridrio
Province or territory
Province ou tcrritoire
C6digo postal
Postal Code
Code postal
Nome do pai
Father's name
Nom du #re
Nome da mHe
Mother's name
Nom de la m&e
Nomes pr6~rios/ Fist Names / PrCnoms
Dam de nascimento
Date of birth
Date de naissance
Lugar de nascimento
Place of birth
Lieu de naissance
Dia
Day
Jour
Mis Ano
Month Year
Mois Ann&
I/-
Apelidos / Surnames / Noms de Famille
Cidade ou localidade
City or town
Ville ou village
Distrito ou provincia
District or province
District au province
Freguesia
Parish
Puoisre
PlIs
Country
Pays '
- 1-
1.6.
Estado civil (marcar V)
Marital status (check h e appropriate box)
h a t civil (cochez la case appropride)
Solteiro(a)
Single
Ctlibataire
1.7.
Casado(a)
Mamed
Mariee)
ViGvo(a)
Widower(widow)
Veuf(veuvc)
Divorciado(a)
Divorced
DivorcC(e)
Separado(a)
C) Separated
Separd(e)
ProfissXo exercida nos w f anos anteriores ao requerimento
Occupation held in the last three years prior to the claim
Profession exercde dans les wois dernikres ann&s prCcedant la demande
Se, ap6s o requerimento continuar a exercer protissiio. qua1 ?
After having made the claim do you continue working ? Spkify:
Est-cc que vous continue2 h exercer m e profession aprL avoir present6 la demande? Indiquez laquelle.
1.8.
Caixas de PrevidEncia ou Centros Regionais de Seguranp Social para onde descontou em Portugal
Social security Funds or Regional Centres to which contributions were made in Portugal
Caisses ou Centres RCgionaux de Stkuritt Social ob vous avez cotis6 au Portugal
Denominaqiio /Name / Nom
1.9.
Datas / Dues I Dates
NJmem de Seguranqa Social
Social Security number
Numtro d'assurance sociale
A~CITOIA
De/From/De
AAAA-
Ad-
/
IJ-
/
22-
Recebe pens50 de acidente de hpabalhoou doenqa profissional ?
Are you receiving a work-related pension as the result of an accident or occupational disease ?
Recevez-vous une pension suite B un accident du travail ou h m e maladie professionnelle ?
NHo /No / Non
Sim/Yes/Oui
Valor mensal da pensb
Monthly amount of pension
Montant masuel de la pension
InstituiqHo devedora
Paying institution
Institution &bitrice
1.10. Recebeu ou vai receba alguma indemnizaqIo an consequhcia de acidente da respawabilidade de taceiros 7
Have you received or will you receive compensation as a result of an accident caused by a third party ?
Avez-vous dtjh y u ou allez vous recevoir une prestation en raison d'un accident de la rcsponsabilitCd'un tiers ?
Sim /Yes / Oui
Valor / Amount / Montant
NHo /No / Non
Global
.Lump-sum payment
Global
Mensal
Monthly Amouns
Mensuel
1.11. Trabalhou noutros paises e wteve al abrangido pela seguraqa social ?
Have you worked in other countries where you had social security coverage 7
Avez-vous travail16 d m un autre pays ob vous Ctiez assujetti h la Sccuritk sociale ?
sim/Ycs/Oui
NH./No/Non
Datas / Dates / Dates
Pds / Coun~ry/Pays
De/From/De
A~CITOIA
2
3
2
2
2
-
2
3
-
J
J
-
2.
2.1.
INFORMAC~ESSOBRE 0 CONJUGE /INFORMATION CONCERNING THE SPOUSE I RENSEXGNEMENTS C O N ~ R NANT LE CONJOMT
Nome. pr6prios / First names / RbKlms
Apelidos / Surnames/ Noms & famille
1
0 s cidadaos de origan portuguua devan indicu os nomes prdprios e apelidos tal como constam an documentooficial portugu6.s
de idcntidadc ou psssaporte)
Citizens of Portuguese origin must indicate thciu first names and surnames as shorn on an official Pomguac document (identity card or
p=spon)
Les citoyens d'origine portugaise doivent indiquer l e w prborns ct noms de famille ~ l qu'indiqub
s
sur un document officiel p ~ w g a i s
(carte d'identid ou passeport)
2.2
Da~adenrscimento
Dak of birth
Date de n a i s s ~ c e
Data de casamento
Date of marriage
Date de mariage
Dia
Day
Jour
Dia
Day
Jour
Mis Ano
Month Year
Mois Ann&
I/-
I
RofssBo
Occupation
Profession
M6s Ano
Month Year
Mois Ann&
22-
;
:
23. 0 dnjuge exem urn actividade s a l h d a 7
I
Is your spouse a salpied anployee ?
Votre mnpint urnce-1-il(elle) m e activid s a k i & 7
Valor do salalkio mensal
Amount of monthly salary
Montant du salaire mensue1
Non
Oui
Non
DcmmbqaO da uuidade patronal
Employen'name md addms
Nom et adresse & l'employeur
2A. 0 chjuge exem uma rctividak nib Mlariada 7
Is your spouse self-employed 7
Votre conjoint exerce-t-il (elle) un emploi autonome 7
Valor m a d das r e t r i i
Monthly income from r e l f u n p l o y m ~
Revenu mensue1 & cet anploi
Ramo de actividade
Type of activity
Geme d'activid
25. Chixu & Revidioei. ou c a m s Regionais & Segunnp Social
para on& o odnjuge desumta ou dscmtou
So& Seapity Funds a R e g i d C a m s to which your
rpouse c o n t r i ~ o r h u
conaibutsd
Cakes ou Ce;urcz RCgiauux & S&uritC Socide oh votre
conjoint cotise ou a cotisC
2.6.
0 dnjuge ~cccbeou n q m u qudquer pensb 7
Does your spouse receive or has he or she applied f a a p i o n ?
Votre conjoint repit-il (elle) une pension ou a-t-il (elle) demand6 m e pension 7
Vllormensaldapentllo
Monthly mount of pension
Montant macucl de la pension
2.7.
Ndmerr, & S c g m q a Social
Social SecuritynMlbr
Num&u d'rssurtnce d
Sim
rJYa
Oui
e
UE'
Non
I n s t i t u w devedon
Paying institution
Institution dtbimce
Outm r e d h m m s do ehjuge / Spwse'r o t h a income/ Autns revenus de votre ampint
Valor m w a l
Monthly mount
Monunt mensucl
::
Oui
Nahlrezr dos rendimentos
Type of income
Genre & revmu
I
3.
RENDIMENTOS DO SECURADO I INCOME OF THE INSURED PERSON I REVENU DE L'ASSURB
I
P e n s k 1 Pensions 1 Pensions
I
3.1.
I
a
Valores mensais
Monthly amounts
Montants mensuels
Instituifies devedoras
Paying institutions
Institutions dtbinices
3.2. Montane dos salMos recebidos pel0 uercicio & uma actividade profusional salariada
Income from salaried employment
Revmu d'un emploi salurit
Dmonhqiio e enduqo dar mtidades p a ~ ~ ~ n a i s
Employers' names and addresses
Noms et dresses des employem
Salhio mensal
Monthly salary
Sdaire mencuel
33. Rmdimmtoa Uquidos pelo uadci de actividrde como comerciank
Net income from h e openlion of a business
Revenu net provenant de I'opCrarion d'un cmmmeroe
Redimento mmsal pelo exackio da actividadc
Monthly income from business
Revmu mmsuel proverwt du commerce
I
3.4.
'
4.
Lucre d&
e x p l o ~
Year's profit
Profit annuel
~
Rmdimentns wmuns do regun& e do h j u g e
Joint income of the insured person md spouse
Revenu commun & I'assurt et du conjoint
V a l m mcnsais
Monthly amount
Montant mensue1
Natureza dos mdimmtos
Type of income
Garnderevaru
INFORMAC~ESSOBRE 0 REQUERENTE COM NECESSIDADE DE ASSISTI~ICIAPERMANENTE DE TERCEIRA
PESSOA
CLAIMANT NEEDING THE CONSTANT ASSISTANCE OF ANOTHER PERSON
RENSElGNEMENTS CONCERNANT LE REQU$WT
QUI A B ~ O I NDE L'ASSISTANCE CONSTANTE D'UNE
TIERCE PERSONNE
I d a t i f i i / Idnrtifiiui011/Identi6catim
Identifca@o da tnrein pcssoa quc pram rsrirtinci
Idenrification of the persun who assists the claimant
Idenficetion de la tierce parorme qui assine le requ&ant
Enderep complcto / Complete A d d m / M m s e
Considera-se que uma pcrsoa tun n d d a d e de assistincia pennancntc de urn urcein quando n b possa praticu com auconomia or wtns
indispcdveis A srtisfaqiiodar rucessiddcshumanas k i c m (cuidados& higimepessoal. [email protected]@o). DEVE SER CERTLFICA,
DO A T R A V J DE
~ RELAT~RIOM ~ D I C O .
The person concerned is deuned to nced constant usisterm of mother person whar the adinaty h v i t i e s of everyday life a n not be perfmmed by him/hasclf (puwnal hygiene.feeding. movement). MEDICAL REPORT MUST BE PRESENTED.
Or considbe qu'une patorme r W
n
i & r~irrurce
canstante d'une tiace p a o n n e si elle ne peut prr s'occuper d'elle mime ( h y g i h
~ l l e. l i. m d o n . locomotion). ON DOIT P R ~ E N T E RUN RAPPORT M ~ ~ I C A L .
-
-
-
Pelo present&solicito as prestq8u de InvalidezIVelhiceda Seguran~aSocial Portuguesa. Declare quepeloconhecimentoque tcnho sobre
as infomaq&s dadasno presenterequaimento, alas siio verdadeiras ecompletasecomprometo-mea avisar o Cmtro Nacionalde Pens6es
de qualqua alteraqlo que posse afectar o direito hs prest@es.
I hereby apply for Ponuguese Disability or Old Age bcnefiu. I declare thal, to be best of my knowledge, the information provided in this
application is accurate and complete and I undenake to inform the National Pension Centre in Portugal of any changes which may affect
my entitlement to benefits.
Par les prkentu, je demande des prestations portugaises d'invaliditbou de vieillesse. Je dbclare qu'8 ma connaissance. les renseignemenu
foumis dans la prCsenre demande son1 vdridiques et compleu et je m'engage ?I aviser le Centre National des Pensions du Portugal de tout
changement pouvant affecter le droit aux prestations.
2
-
Data / Date / Date
Assinatura / Sinnature / Sipnature
DECLARA~KO DA TESTEMUNHA SE 0 REQUERENTE ASSINOU POR ME10 DE (X)
DECLARATION OF WITNESS WHEN APPLICANT SIGNS BY MARK (X)
D$CLARATION DU TBMOIN SI LE REQU$RANTSICNE D'UNE CROIX (X)
NOTA: A assinatura feik por meio deuma cruz (x) s6 C vslida quando esta declara~Io6 assinada por uma testanunha que conhea o requamte.
NOTE:
Signature by mark (x) is aoceptable if a witness who knows the applicant signs this declaration.
A NOTER: La signature au moyen d'une croix (x) n'est valide que si un ttmoin qui comait le nqutrant s i p ceae &laration.
I
Li o wnteddo do pruente pcdido ao requerente que panceu compreend2-loe assinou com urna (x).
I have read the contenu of this application to Ihe applicant who appeared to understand them and who made his or her mark (x).
J'ai lu le contenu de la presente demande au requ&ant qui a sembl6 le comprcndre et qui a sign6 d'lme croix (x).
-
6.
-
-
ASSINATURA DA TESTEMUNHA (em leaa conente)
SIGNATURE OF WITNESS (do not print)
SIGNATURE DU TEMOLN(ne pas signer en lettre moul6es)
Data
Date
Date
ENDEREGO DA TESTEMUNHA
ADRESS OF WITNESS
ADRESS DU TEMOIN
NP de Telefone
Telephone no
NP de telephone
PARA US0 EXCLUSIVO DOS SERViCOS I FOR OFFICE USE ONLY I A L'USAGE EXCLUSIF DU BUREAU
Para ser compleudo pcla instituigo competmte do Canad4
To be completed by the competent institution in Canada
A 2- compltt6 par I'ititution compCtentc du Canada
Cmifiw que os elemcntos de idmtifica@o contidos no presente formulMo foram retindos dos documentos oficiais apresmudos pel0
requercnte.
I hereby certify that the vital statistics data contained on this form are taken from official documents provided by the applicant.
Par les prtsentu, j'atteste que les donnCcs pcrsonnelles inscrites sur ce formulaire ont Cd tirtes des documents officiels foumis p le
requkant.
r
Dia
Day
Jour
Data de entrada do nquerimento
Date application receivcd
Date de rhplion ce la demande
1
M2s Ano
Month Year
Mois Ann&
IdData / Date/ Date
/
I
Carimbo ou selo branw
S m p or blank seal
T i b e ou stew sec
L
J
Assinatura / Signature/ Signature
b
Canada / Portugal Agreement
Documents and/or information required to support your application [CDN - P 1]
for a Portuguese Old Age and/or Disability Pension
Complete the attached form:
•
Canadian Residence [ISP 5013] [only if you have less than 10 years (for an Old Age pension)
or 5 years (for a Disability pension) of contributions to the Canada Pension Plan]
Original or certified documents to be submitted:
•
Birth certificate or Cédula Pessoal
•
An official Portuguese document indicating your full name, birth and birthplace (such as: birth or
baptismal certificate, Cédula Pessoal, identity card, or passport)
•
Proof of the dates of your entry(ies) to Canada and departure(s) from Canada (such as:
Immigration 1000, passport, visa, ship or airline tickets, etc.) [only if you have less than 10 years
(for an Old Age pension) or 5 years (for a Disability pension) of contributions to the Canada
Pension Plan]
•
Medical report if you require the constant assistance of another person. If this is the case, you
must also complete section 4 of the application form.
A copy of the following document must be submitted:
•
Taxpayer card (if available)
IMPORTANT: If you have already submitted any of the documents required when you applied
for a Canada Pension Plan or Old Age Security benefit, you do not need to
resubmit them.
Human Resources
Development Canada
Développement des
ressources humaines Canada
Protected when completed - B
Personal Information Bank
HRDC PPU 175
CANADIAN RESIDENCE Canadian Social Insurance Number
Mr.
Mrs.
Ms.
Miss First Name and Initial
Last Name
The following information is required to support your application for benefits under a social security agreement.
If required, please provide additional information on a separate sheet of paper.
1. If you were born outside of Canada, please provide us with the following information:
• Date of arrival in Canada:
• Place of arrival in Canada:
2. List all the places where you have lived in Canada after the age of 18 and provide proof of all your entries and
departures (immigration 1000, complete passport, airline tickets, etc.):
From (Year/Month/Day)
To (Year/Month/Day)
City Province/Territory 3. List all absences from Canada, which were longer than six months, during your Canadian residence listed in
number 2 above:
Departure (Year/Month/Day)
Return (Year/Month/Day)
Destination (Ce formulaire est disponible en français - ISP 5013 F)
HRDC ISP5013 (2005-08-002) E
Page 1 of 2
Reason Canadian Social Insurance Number
4. Please give us the names, addresses and telephone numbers of at least two people, not related to you by blood or
marriage, who can confirm your Canadian residence:
Address Name City Telephone Number (
)
-
(
)
-
DECLARATION OF APPLICANT I declare that this information is true and complete. (It is an offence to make a misleading statement) Signature:
X Telephone number:
Date:
(
HRDC ISP5013 (2005-08-002) E
)
Year
-
Page 2 of 2
Month
Day